Issue one: Patients being discharged before they are clinically ready to leave hospital

A failure to properly assess an individual's medical fitness to leave hospital can seriously compromise patient safety. Our casework shows that mistakes at this fundamental level have tragic consequences, including potentially avoidable deaths.

Mrs T died in her granddaughter's arms after being discharged too soon with severe stomach pain

What happened

Mrs T, who was in her late 90s, fell ill at home. Her granddaughter called a GP to see her, who diagnosed a bladder infection and also noticed that Mrs T's stomach was swollen. She became unwell overnight so her granddaughter called an ambulance which took Mrs T to hospital. The ambulance crew also noticed Mrs T's stomach was swollen. At the hospital Mrs T was examined by a doctor who ordered a urine test but did not focus on the severe stomach pain she was having. Mrs T was told she had a bladder infection. She was discharged and the doctor advised her to drink more fluids.

Just after the ambulance had dropped her home and left, Mrs T collapsed and died in her granddaughter's arms. A post mortem showed Mrs T had died from an infection in her large intestine and an infection of the tissue that lines the tummy; symptoms of both included abdominal pain.

Just after the ambulance had dropped her home and left, Mrs T collapsed and died in her granddaughter's arms.'

What we found

Mrs T was very unwell and had the doctor physically examined her stomach, it's highly unlikely that she would have been sent home. If she had been examined, it would have been clear to Mrs T's family that she was very ill and that there was a risk of her dying. Instead she was discharged home where she died suddenly, causing Mrs T's granddaughter a great deal of shock and distress.

A man died after a hospital failed to treat sepsis appropriately

What happened

Mr L went into hospital with a painful lump on his buttock, and tests showed that it was infected. Doctors tried unsuccessfully to remove fluid from the lump but decided there was no need to send Mr L to the operating theatre to have the lump surgically drained. The hospital discharged Mr L home with antibiotics. He returned to hospital three weeks later with intense pain in his foot and was found to have an infection (sepsis), which had spread. Mr L died four days later.

Mr L's daughter complained to the hospital, because she felt that more could have been done to treat and care for her father and that he should not have been discharged so soon. The hospital acknowledged that the infection had probably originated in the lump on Mr L's buttock. However, it felt this had been treated appropriately and that the infection he had on his second admission was unlikely to have been caused by any treatment he had when he first went into hospital.

Mr L showed signs of sepsis on his first admission, so he should have been kept in hospital.'

What we found

Mr L showed signs of sepsis on his first admission, so he should have been kept in hospital and his lump should have been surgically drained. We felt that had he been treated appropriately, he may not have developed sepsis and died. This failing by the hospital caused Mr L's family considerable distress.